The Lancet
Sep 13, 2014 Volume 384 Number 9947 p929 – 1070 e38
http://www.thelancet.com/journals/lancet/issue/current

Editorial
The silver bullet of resilience
The Lancet
The irony of September being US National Preparedness month was not lost as Médecins sans Frontières (MSF) made an uncharacteristic global call for rapid deployment of civil and military medical assets with expertise in biohazard containment to west Africa. With 42% of all reported Ebola infections occurring in the past month, and more than 2000 reported deaths, local health systems and international organisations were not prepared for the scale and speed of the current outbreak. MSF called for countries such as the UK and USA to deploy disaster response teams with medical and logistical experts for water and sanitation, building of mobile laboratories, isolation centres, hospitals, crematoriums, and the establishment of dedicated air bridges to move personnel and equipment between countries. On Sept 7, the US government announced that their military would be mobilised to set up isolation units and equipment, and provide security for public health workers.

Delayed international action has been largely blamed on the chronic underfunding and inability of WHO to mount an adequate initial response to manage the outbreak. This institutional failure begs first and foremost an urgent rethink of how the world responds to outbreaks, and with whom. The second equally important task is building resilience into health systems.

The notion of resilience is defined as the capacity to adapt and thrive in the face of challenge. For health organisations, this could mean creating more redundancy and organisational slack to respond efficiently to crises. For companies, it might mean rethinking the development pipeline of their products, delinked from profit, to contribute to a better prepared world. For countries and their partners, it means investing in weak health systems, building back the trust of communities, and examining the complex interactions between people and the environment. However, to earn the luxury of a much needed resilience debate for west Africa, countries and international organisations must heed the call to immediately deploy medical assets to contain the Ebola outbreak and offset further deaths.

Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Haidong Wang, et al.
Summary
Background
Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success.
Methods
We generated updated estimates of child mortality in early neonatal (age 0—6 days), late neonatal (7—28 days), postneonatal (29—364 days), childhood (1—4 years), and under-5 (0—4 years) age groups for 188 countries from 1970 to 2013, with more than 29 000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030.
Findings
We estimated that 6•3 million (95% UI 6•0—6•6) children under-5 died in 2013, a 64% reduction from 17•6 million (17•1—18•1) in 1970. In 2013, child mortality rates ranged from 152•5 per 1000 livebirths (130•6—177•4) in Guinea-Bissau to 2•3 (1•8—2•9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from −6•8% to 0•1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000—13 than during 1990—2000. In 2013, neonatal deaths accounted for 41•6% of under-5 deaths compared with 37•4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1•4 million more child deaths, and rising income per person and maternal education led to 0•9 million and 2•2 million fewer deaths, respectively. Changes in secular trends led to 4•2 million fewer deaths. Unexplained factors accounted for only −1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone.
Interpretation
Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030.
Funding
Bill & Melinda Gates Foundation, US Agency for International Development.

Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Nicholas J Kassebaum, et al
Summary
Background
The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100 000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.
Methods
We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990—2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.
Findings
292 982 (95% UI 261 017—327 792) maternal deaths occurred in 2013, compared with 376 034 (343 483—407 574) in 1990. The global annual rate of change in the MMR was −0•3% (—1•1 to 0•6) from 1990 to 2003, and −2•7% (—3•9 to −1•5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290—2866) maternal deaths were related to HIV in 2013, 0•4% (0•2—0•6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956•8 (685•1—1262•8) in South Sudan to 2•4 (1•6—3•6) in Iceland.
Interpretation
Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.
Funding
Bill & Melinda Gates Foundation.
Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Christopher J L Murray, et al
Summary
Background
The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration.
Methods
To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010—13) of incidence, drug resistance, and coverage of insecticide-treated bednets.
Findings
Globally in 2013, there were 1•8 million new HIV infections (95% uncertainty interval 1•7 million to 2•1 million), 29•2 million prevalent HIV cases (28•1 to 31•7), and 1•3 million HIV deaths (1•3 to 1•5). At the peak of the epidemic in 2005, HIV caused 1•7 million deaths (1•6 million to 1•9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19•1 million life-years (16•6 million to 21•5 million) have been saved, 70•3% (65•4 to 76•1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7•5 million (7•4 million to 7•7 million), prevalence was 11•9 million (11•6 million to 12•2 million), and number of deaths was 1•4 million (1•3 million to 1•5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7•1 million (6•9 million to 7•3 million), prevalence was 11•2 million (10•8 million to 11•6 million), and number of deaths was 1•3 million (1•2 million to 1•4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64•0% of cases (63•6 to 64•3) and 64•7% of deaths (60•8 to 70•3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1•2 million deaths (1•1 million to 1•4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31•5% (15•7 to 44•1). Outside of Africa, malaria mortality has been steadily decreasing since 1990.
Interpretation
Our estimates of the number of people living with HIV are 18•7% smaller than UNAIDS’s estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action.
Funding
Bill & Melinda Gates Foundation.